Manipulative Histrionic Craves Attention: HPD Misconceptions Debunked (Literature Review)

Uploaded 5/4/2024, approx. 23 minute read

We have all had the misfortune of coming across these types.

The hyper-muscular gym rat, who is also over-emotional and whiny and hypochondriac.

The flirtatious woman who aggressively flings herself at anything that moves and then becomes hysterical when rebuffed.

These are the cliches or the stereotypes of histrionic personality disorder.

And today we are going to review the cutting edge, bleeding edge, not pun intended, of the literature.

The most recent studies in the past five years are threatening to upend our perception of histrionic personality disorders.

We've gone through a cycle.

We started by considering histrionic personality disorder as a form of narcissism.

And then we transitioned and there were scholars who suggested that histrionic personality disorder is a form of female psychopathy.

And today we are coming back more or less full cycle back into narcissism territory and a few added very fascinating features.

So stay with me.

My name is Sam Maknin.

I'm the author of Malignant Self-Love, Narcissism Revisited, a former visiting professor of psychology and currently a professor of psychology and of management studies in CEOPS.

Histrionic personality disorder.

It is sometimes also called the dramatic personality disorder.

It's a cluster B disorder and it's characterized by a pattern of exaggerated attention seeking behaviors and emotionality.

Now this is an artificial distinction because the histrionic uses ostentatious in your face emotionality in order to attract attention.

So the histrionic's emotionality is largely an instrument, a way to manipulate the environment and extract favorable outcomes.

The self-efficacy of the histrionic relies on the externalization of her emotions, the exaggeration of her feelings and the communication of these inner stirrings and processes to an unwilling usually audience or crowd.

She's a performer.

He is an actor.

Now we don't have exact statistics.

The belief was that vast majority of people with histrionic personality disorder are women.

That gender bias is long behind us and today we believe that it's more or less 50/50.

To remind you, other cluster B personality disorders include antisocial personality disorder, the extreme form of which is known as psychopathy, borderline personality disorder which has a self-state as a secondary psychopath when the borderline is exposed to stress or to anxiety or to rejection or to humiliation or to abandonment, real or anticipated and narcissistic personality disorder.

And all these are known as the excitable, erratic, dramatic or volatile cluster.

In short, the kind of people you want as your friends, as your spouses and as your colleagues.

All right, Shoshanim, that was a joke, of course.

Now patients with histrionic personality disorder exhibit unique behaviors.

They can be charming and often are.

They're always flirtatious.

They're the life of a party.

They're manipulative and even sometimes Machiavellian and they're always seductive.

But some of them are flirtatious and seductive by displaying sexual behavior that is known as hyper sexualized behavior, by acting flirtatious, by signaling availability, sexual availability.

All those studies have repeatedly demonstrated that people with histrionic personality disorder hate sex, believe it or not.

Still, they use sexual signaling in order to attract attention and to conquer the element of chase and conquest, a very important in histrionic personality disorder.

But there's a subgroup of histrionics who attract attention by emphasizing their neediness, their helplessness.

They elicit the savior or the fixer complex in other people.

They pretend to be in need of some service or some rescue or some input.

And this way, they emotionally blackmail people around them into submission and collaboration.

Patients with histrionic personality disorder.

Therefore I'm not monolithic.

This is not a monolithic disorder.

You could find many variants.

But what is common to all these behaviors, sometimes diametrically opposed behaviors, is attention.

The garnering of attention, the processing of attention, the manipulation of attention, the interactions that involve an exchange of attention.

It's the attention economy in effect.

Okay, now, histrionic personality disorder emphasizes the body.

Emphasizes the body because body equals sex and sex equals attention.

Also these kind of people somatize emotions.

They display emotions via bodily gestures, body posture and body language.

It is not a surprise, therefore, that histrionic personality disorder is intimately linked with somatoform disorders and has important comorbidities with other mental health disorders which have to do with the body.

It's a body complex in effect.

So there's been a recent review and you try to find whether there's any connection between histrionic personality disorder and race, racism or gender bias in diagnosis.

And the belief is that we tended in the past well into the 1980s or 1990s, we tended to group mental health disorders according to gender and sometimes according to race, but definitely according to gender.

So for example, we held the belief that borderline personality disorders, emotional dysregulation, this disorder is common among women.

It's a female disorder.

Similarly histrionic personality disorder was perceived to be a woman's business, a woman's issue and narcissism was male.

And so recently we've been unwinding this gender bias.

The survey indicated, the review indicated that gender bias does occur in the diagnosis of histrionic personality disorder as well as by the way in ADHD, attention deficit, hyperactivity disorder and in autism spectrum disorder.

In all of these, there's gender bias.

And the study was offered by GARB, G-A-R-B, entitled race bias and gender bias in the diagnosis of psychological disorders.

It was published in the journal clinical psychology.

Now in the description, which is still under the video, in the description, you will find the literature, a list of the articles have relied on to produce this video.

The results of this review indicated that race bias occurs in the diagnosis of eating disorders, comorbid mood disorders and substance abuse, post-traumatic stress disorder and the differential diagnosis of psychotic affective disorders in schizophrenia.

But there was no race bias when it came to histrionic personality disorder, only gender bias.

The researchers found that racialized manifestations of symptoms such as black cultural expressions of depression, blacks express depression differently to whites, for example.

The clinical interpretation of these behaviors and these displays and these outward signs and symptoms, these critically affect diagnosis.

So there's no cultural sensitivity and there's no gender sensitivity in diagnosing.

The research also indicated that it might be possible to decrease bias by using self-report measures including psychological tests, mental health screening, structured interviews and statistical prediction.

But we are very far from it at this stage.

The diagnosis of personality disorder should include training in cultural diversity, dimensional ratings, the biasing strategies, but again, we're very, very far from it.

So this is point number one.

Histrionic personality disorder is most probably equally represented among men and women, but we don't have sufficient data to support this contention or this assumption because we have been gender biased when we diagnose people.

If a man presented with all the signs of histrionic personality disorder, it is like the person, the man would have been likely diagnosed with narcissism.

Whereas if a woman presented with these signs and symptoms, she would likely have been diagnosed with borderline or histrionic personality disorder.

Next, there was a prospective follow-up study to this and it aimed to report the presence of categorical and dimensional personality disorders, including histrionic personality disorder in adults with long-standing eating disorders lasting more than 17 years.

And to investigate whether changes in personality disorder symptoms predict changes in symptoms of eating disorders and so on.

So in short, this follow-up study tried to find the connection between histrionic personality disorder and eating disorders.

Now intuitively, we would tend to assume that people with histrionic personality disorder, which is essentially a somatic disorder, it's a disorder that makes use of the body in order to manipulate the environment and regulate internal processes in the patient.

So we would tend to assume that personality disorders so focused on the body would be linked to eating disorders, would be linked to somatophobias disorder.

The study was authored by Eilson, Wabel, Hoffart and others and it's titled Reciprocal Relationships between Personality Disorders and Eating Disorders in a prospective 17-year follow-up study.

It was published in the International Journal of Eating Disorders, again, literature in the description.

What they found is that high levels of personality disorders were predictive of eating disorders, but this association was strongest not for histrionic personality disorder, but for borderline personality disorder.

In other words, borderlines were much more likely to have eating disorders than histrionics, surprisingly.

Although histrionics tend to be far more invested in diet fads, cosmetic surgeries, plastic surgeries, you name it, the borderlines are the ones who engage in eating disorders.

And possibly one of the reasons is that eating disorder is a form of reasserting control over one's life and the borderline feels that her life is out of control and so she can't control her life, but she can control her food intake, which is a great definition of an eating disorder.

Where the association was observed in patients with histrionic personality disorder, the researchers in this study saw that long-term treatment reduced both eating disorder symptoms and personality disorder symptoms.

And this was in line with other studies over the past two decades where we found out that when you treat one of the pair of comorbidities, it has an effect on the other member of the pair.

So if you have a patient with two diagnoses, three diagnoses, six diagnoses, if you treat one or two of them, the others also get better, also get ameliorated, even if you did not treat them specifically.

It's a very interesting trend or discovery.

Again, the only exception was borderline personality disorder, which was totally resistant to treatment.

So we know by now that narcissistic personality disorder is resistant to treatment, but we are finding out that when we treat comorbidities, when we treat situations where the same person is diagnosed with multiple mental health issues, borderlines are most resistant.

When there is narcissistic personality disorder in conjunction with other mental health issues, it's possible to treat the other mental health issues.

For example, obsessive compulsive disorder, depression, we can treat these in narcissists.

We cannot touch the narcissist, the pathological core of narcissism, but we can touch the comorbidities.

With borderlines, it's exactly the opposite.

We can treat the core of borderline, the engine of borderline personality disorder.

We have treatment modalities, which are very efficient, and efficacious with borderline personality disorder, for example, DBT, but we fail to treat the comorbidities.

It seems that the borderline is emotionally invested in her other mental health disorders.

A borderline with it and eating disorder would be emotionally invested in the eating disorder, but she would like to get rid of the borderline disorder.

And that's why treatment is successful there, and a failure here.

There was an exploratory analysis, which investigated possible differences in medical and psychosocial parameters between patients with vaginismus and patients with other sexual symptoms among various female patients.

So, women came to clinics and they reported sexual dysfunctions.

Vaginismus was one of them, and this was compared to the prevalence of histrionic personality disorder in this population, in this cohort.

The studies titled "Psychobiological Correlates of Vaginismus", an exploratory analysis, it was published in the Journal of Sexual Medicine.

The authors, the lucky authors, Amaseroli, Scavello, Cicugiani, and other Italians, and the researchers found no differences for traditional risk factors, such as the history of genealogical diseases, sexual abuse, or relational parameters, or even for newly investigated parameters, such as hormonal, neurological, or metabolic alterations.

None of these had any predictive value, but they did find that patients with vaginismus showed significantly higher histrionic hysterical symptoms.

Vaginismus, as I'm used to pronouncing it, Vaginismus seems to be connected to histrionic personality disorder, or at the very least, to some histrionic traits and behaviors, or hysterical traits or behaviors, compared with other sexual symptoms.

After adjustment for age, patients with vaginismus had significantly higher total scores on the female sexual function index and female sexual distress scale revised.

It is known as the FSDS.

The FSDS total score increased with the duration of vaginismus in age-adjusted model.

So, the problem tends to exacerbate with age.

It doesn't become better, it becomes worse.

The researchers concluded that histrionic traits should be investigated as novel contributions or contributors to vaginismus and other forms of sexual dysfunction, and that histrionic traits as a psychological comorbidity could offer clinicians valuable insights for managing complications in patients experiencing vaginismus and other sexual dysfunctions.

You remember what I told you earlier?

I told you that people with histrionic personality disorder dislike sex.

And one of the reasons they dislike sex is the fact that they suffer from multiple sexual dysfunctions, some of which, like vaginismus, are highly painful.

And that, of course, applies only to women.

At this stage, only women have vaginismus.

Now, there was another study aimed to estimate the extent of overlapping etiology between response to caffeine consumption, coffee, coffee consumption, or Coca-Cola consumption, and normative pathological personality.

You see, psychologists are going everywhere.

Is coffee consumption related to histrionic personality disorder?

Is sexual dysfunction related?

Is there anything else we've missed?

They're trying to form an integrative view of histrionic personality disorder and other mental health issues.

Anyhow, this particular study focused on caffeine, coffee, Coca-Cola, other drinks, energy drinks with caffeine and so on.

The researchers found that caffeine was somehow moderately related to personality disorder, but I'll try to explain how.

The first thing these scholars, these researchers established is that caffeine measures, including, for example, caffeine tolerance, are moderately heritable.

There is a genetic component in how we react to caffeine and that all four personality traits, antisocial, borderline, dependent, and paranoid, are significantly associated with at least one caffeine variable.

Now, it's very difficult to tell whether people who are antisocial, borderline, dependent, and paranoid consume caffeine or whether the caffeine created some changes in the brain or elsewhere, an induced mental illness, or whether there's a third factor unknown at this stage, which creates both caffeine tolerance or caffeine interactivity and personality disorders.

We don't know yet.

They found that a small proportion, about 11% of the variance in caffeine consumption, was attributable to genetic factors shared with personality disorders.

So it seems you have the same genes for personality disorders and for caffeine consumption.

And histrionic personality disorder was the only exception, amazingly.

It was not linked to any caffeine-related behaviors, which I'm sure is a sigh of relief.

But if you're histrionic, at least you're not addicted to caffeine.

Thank God for the researchers for small favors.

Antisocial personality disorder was linked to higher daily use of caffeine or consumption of caffeine.

And both antisocial and borderline personality disorders were linked to caffeine toxicity.

Borderline personality disorder was linked to caffeine tolerance.

Caffeine seems to be somehow connected to personality disorders via some kind of genetic conduit or genetic channel.

It's not clear at all at this stage.

And to another study, a population-based twin study, my favorites. My favorite studies are randomized trials on twins, especially identical twins.

These identical twins are basically copies of the same person, clones.

So we can forget the genetic part and focus on the environment, forget nature and focus on nurture.

So twin studies are far more valuable, in my view, than any other type of study in psychology.

So here's a study, population of twins, which aim to determine which personality disorder traits were linked phenotypically and genetically to cocaine use, from caffeine to cocaine.

Who knows what's next?

So the study was authored by Gillespie, Agen, Gentry and others, many others.

And it's titled testing genetic and environmental associations between personality disorders and cocaine use, a population-based twin study, and it was published in a journal, a academic journal dedicated to twin studies, twin human genetics.

Again, in the literature, you can find a reference to this study.

Not so surprisingly, the researchers discovered, presumably not under the influence of coke, they discovered that having antisocial and borderline personality disorder traits, these were significant predictors of cocaine use.

If you were a psychopath, or even if you had only, were diagnosed only with antisocial personality disorder, this would explain 72% of the reason why you are using coke.

There's no need for any other input or parameters, socioeconomic, education, upbringing, family background, none of these were remotely as important in explaining why you are using coke as the fact that you have antisocial personality disorder, 72%.

Similarly, someone with borderline personality disorder.

Borderline personality disorder in itself accounted for 25% of the explanation for cocaine use.

In other words, if you were diagnosed with antisocial personality disorder, or borderline personality disorder, you were more likely to use coke, to use cocaine.

Much more likely if you're antisocial, and considerably more likely if you were borderline.

And total genetic risks, the predisposition, the predictability of cocaine use increased dramatically with the diagnosis of antisocial and borderline personality.

There was a modest correlation of genetic risks, also in histrionic personality disorder, but it was not related to cocaine use.

They are beginning to see that people with histrionic personality disorder, contrary to the myths and stereotypes, are actually not prone to substance abuse.

Antisocial, people with antisocial personality disorder, people with borderline personality disorder are prone to substance abuse.

They abuse coke, they abuse caffeine, they abuse cocaine, they abuse drugs, they abuse alcohol, but this is not common among people with histrionic personality disorder.

And this of course, flies in the face, defies everything we thought we knew about histrionic personality disorder.

And finally, there's a clustering analysis published that aimed to empirically classify patients with internet gaming disorder on the basis of personality variables and describe the resulting groups in terms of social, demographic, and clinical struggle.

So the study is titled Internet Gaming Disorder Clustering Based on Personality Traits in Adolescence and its Relation with Comorbid Psychological Symptoms.

The authors are Gonzalez Buesso, Santa Maria, and others.

And the researchers observed that patients were grouped in two clusters of high and low comorbid symptoms.

Patients with histrionic traits were in the cluster with low comorbid symptoms.

And this is again very interesting.

It flies in the face of our common popular misperceptions of histrionics.

We think histrionics are loose.

We think histrionics are out of control.

We think histrionics are disinhibited.

Actually the emerging picture is that histrionic personality disorder is a form of rigid self-control, no substance abuse, no internet addiction.

These are people who are goal oriented, focused on obtaining attention.

And the way they obtain attention is by acting hyperemotional, by ostentatiously displaying their emotions, and by being seductive and flirtatious.

It begins to look indeed as a variant of Machiavellianism, as a kind of dark personality, albeit not psychopathic.

So it was a mistake to consider histrionic as a psychopathic disorder.

But it is not a mistake to consider histrionic as a kind of dark personality, because histrionics have narcissistic components, psychopathic behaviors, and a lot of Machiavellianism.

And this is a great description of the dark triad personality.

There was a recent study aimed to detail how sexual abuse, physical or emotional neglect, and other forms of childhood trauma, known as adverse childhood experiences, how these might influence histrionic personality pathology relative to others.

So the study is child abuse and neglect on histrionic personality, the influence of child abuse and neglect on histrionic personality pathology, the authors are Yauch, Seroni and others, and it was published in the Journal of Trauma and Dissociation.

Again, all the links and all the references and all the bibliography in the literature in the description.

What they found is that sexual abuse was the strongest predictor, and that women and men who experienced sexual abuse as children were more likely to exhibit histrionic personality traits.

But they also found that physical neglect was linked to histrionic personality traits in adult women, whereas emotional abuse and neglect, along with physical abuse, were all linked to histrionic personality traits in men, different ideologies, same outcome.

They concluded that different clinical interventions might have varying levels of success for adults with histrionic personality pathology, based in part on the differences observed in this study.

And a cross-sectional study aimed to investigate whether rash impulsiveness, impulsivity, and features of each of the cluster B personality disorders, including histrionic personality disorder, were linked by positive alcohol expectancies and indirectly associated with alcohol use severity.

This is a study titled Cluster B Personality Disorder Traits and Impulsivity in Direct Associations with Alcohol Use Severity through Positive Alcohol Expectancies.

And so what they discovered was that traits specific to each cluster B personality disorder and impulsivity were indirectly associated with alcohol use severity through positive alcohol expectancies, both uniquely and together.

And this demonstrates that positive alcohol expectancies can connect people with personalities at risk for impulsive behavior.

They found that positive alcohol expectancies might be more important to increase risk for more severe alcohol use in patients with histrionic traits.

In other words, people with histrionic personality disorder or histrionic traits who favored alcohol, who expected alcohol to have some favorable outcomes, positive alcohol expectancy were more likely to use alcohol and were more likely to use it severely, overuse it.

The current findings showed that patients with borderline histrionic and narcissistic personality disorder traits were less rashly impulsive but remained at risk for increased alcohol use severity owing to other forms of impulsivity, such as negative urgency, agreeableness, excitement seeking, extroversion or neuroticism.

These findings did not extend to patients with histrionic personality disorder traits again.

In other words, these patients were uniquely vulnerable to rashly impulsive behavior, especially those driven by positive alcohol expectancies.

And it is exactly this that ties the knot.

The person with histrionic personality disorder internally is dysregulated, impulsive, maybe even reckless.

Hypersonic personality disorder seems to be a rigid reaction to this, an attempt to discipline the internal turmoil, to regain control internally by gaining control over other people externally.

And this is done in a highly ritualized manner, a bit reminiscent of compulsive, obsessive compulsive.

So, and the ritual involves manipulation via seduction, infiltration, emotional blackmail, hyperemotionality, displays of neediness and so on, coupled with conquest or chase or subjugation of the other.

So it's a power play.

Hypersonic personality disorder has nothing to do with sex.

It has to do with power.

These geonic attempts to abscond with the power of others, to gain power over others, is a way to self-regulate and regain power over herself or himself.

If you enjoyed this article, you might like the following:

Over-sexed: Histrionic Personality Disorder and Narcissism

Histrionic personality disorder is more commonly diagnosed in women, leading to questions about whether it is a real mental health problem or a reflection of a patriarchal society. Histrionics crave attention and are uncomfortable when not at the center of it, similar to narcissists. They are preoccupied with physical appearance and sexual conquests, and often act flirtatious and seductive. Histrionics are enthusiastic and emotional, but their behavior can be exhausting and off-putting to others.

High-functioning Autism: Psychopathy? Narcissism?

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Histrionic Personality Disorder (HPD): Overview and Issues

Professor Sam Vaknin discusses histrionic personality disorder, its comorbidity with other personality disorders, and the various adaptive solutions that collapsed histrionics and narcissists resort to when faced with deficient narcissistic supply. He also delves into the dynamics of histrionic women's interactions with men and the conflicting inner voices they experience.

Body Language of the Personality Disordered

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Antisocial Psychopath and Sociopath: Antisocial Personality Disorder

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Study: Weak Self of Covert Narcissists, Secondary Psychopaths

A study has found that individuals with Cluster B personality disorders, specifically those with dark triad traits, have a weak, unstable, and unclear sense of self. The study's authors suggest that recognizing these traits is important in predicting behaviors and avoiding destructive, impulsive, and callous behaviors. The study also found that high-level dark triad traits are associated with a weaker sense of self, regardless of gender and age. However, when analyzing sub-traits of narcissism, psychopathy, and Machiavellianism, the study found that vulnerable narcissism and secondary psychopathy are most strongly correlated with a weaker or unclear sense of self.

Borderline Woman as Dissociative Secondary Psychopath

Borderline Personality Disorder and Psychopathy may not be as different as previously thought. Recent studies suggest that Borderline and Histrionic Personality Disorders may be manifestations of secondary type psychopathy in women. Survivors of Complex Post-Traumatic Stress Disorder (CPTSD) also exhibit psychopathic and narcissistic behaviors. Borderline Personality Disorder can be described as a subspecies of Dissociative Identity Disorder, with mood lability and emotional dysregulation being outward manifestations of changes in self-states.

Attention Whores, Impulse Control, and Munchausen by Narcissist

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Personality Disorders Gender Bias

The Diagnostic and Statistical Manual (DSM) confesses to gender bias, with personality disorders such as borderline and histrionic being more common among women, while narcissistic, antisocial, schizotypal, passive compulsive, schizoid and paranoid disorders are more prevalent among men. The reason for this gender disparity may be due to culture-bound syndromes, with personality disorders reflecting biases and value judgments of the prevailing culture. Upbringing, environment, socialization, cultural mores, and genetics may also play a role in the pathogenesis of personality disorders. Ultimately, the ambiguity and equivocation of the diagnostic criteria may be the problem, with gender bias being everywhere in the psychiatric profession.

Shyness or Narcissism? Avoidant Personality Disorder

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